[ Reprinted front the Transactions of the Medical and Chirurgicad 
Faculty of Maryland, April, 1878.] 
THE NEW 
Treatment for Chorea. 
BY I / 
JOHN VAN BIBBER, M. D. 
OF BALTIMORE: 
Innes & Company, Printers and Binders. 
BALTIMORE: 
1878.* [Reprinted from the Transactions of the Medical and Chirurgical Faculty of Maryland, 
April, 1878.] / 
THE NEW TREATMENT FOR CHOREA. 
I p 
BY JOHN VAN BIBBER, M. D., of Baltimore. 
Probably no subject in Physiology is more interesting than that 
which treats of the contractile power of muscular fibre, and its 
various connections with the spinal cord, in the production of 
reflex action, or with the brain in the fulfilment of volitional im- 
pressions. If the study of muscular contraction, and the different 
factors concerned in its production, offers so much interest to the 
student of normal life, surely any complication brought about 
by disease to so perfect a system must claim the attention of 
medical men. 
Thus Chorea, with its pathognomonic spasms, offers peculiar 
attractions as an example of a perversion of function. For in 
this disease we have muscular fibre capable of contraction; will 
power capable of volition; conductors to carry impressions, and 
spinal cord responsive to reflex action, yet all these factors are 
so modified and at the same time exaggerated, that natural move- 
ment is impossible, ordinary motions become contortions, and 
efforts end in failures. Actions that under normal physiological 
conditions are accurate and methodical, now become purposeless 
and incoherent, and each muscular contraction brings on a series 
of spasms which gives the body an appearance of uncontrollable rest- 
lessness. Further than this, the daily routine of life, such as 
eating, or the necessary exertion of dressing and undressing, 
produces such irritation, that what in health are considered comforts 
and luxuries, are now converted into so many means of distress 
and torture. The entire mechanism of the muscular system 
seems to have received some deep morbid impression, and the 
study of the causes, the existence, and the treatment of these 
symptoms presents an attractive field for medical investigation. 2 
In a recent compendium of therapeutics I find fifty-one reme- 
dies enumerated as recommended by various authors in the treat- 
ment of St. Vitus' Dance. The compiler says in his preface, " I 
have not attempted to mention every remedy employed for a 
disease, but only such as have some good authority, or else some 
very plausible theory for their use." If with the exercise of such 
discrimination it was only possible by careful examination of the 
literature of medicine to reduce the methods of cure to fifty-one, 
the remedies for the disease must be very numerous, and I should 
beg some indulgence for suggesting in this paper a plan of treat- 
ment which is not included in this lengthy enumeration. 
Of course, in such a long list of remedies, many of them must 
rely entirely on empirical recommendation, and a few others may 
be strengthened by a direct theory of physiological action. But 
it is rare in medical reasoning that we can develop a theory of 
therapeutic action which will escape adverse comment and a long 
list of puzzling interrogation marks. If we can avoid the neces- 
sary uncertainties of medicines, and adopt a treatment which not 
only has common sense, but direct physical reasons in its favor, 
we forestall much criticism, and may induce many to adopt our 
ideas. 
In the Chicago Journal of Nervous and Mental Diseases, (April, 
1877), Prof. Ransom Dexter suggested the indication of entire 
and prolonged rest in the treatment of Chorea, and as far as I 
know this was the first and only publication on the subject. Prof. 
Dexter relates a case of chorea major in which many remedies 
had proved inefficient, and which was much improved by 
such absolute rest as was obtained by closing all means of 
external irritation. The patient was kept in bed, the room was 
darkened, the eyes bound up, and the ears plugged with cotton. 
The result of this procedure was so satisfactory that it was 
published to the profession. But Professor Dexter fell into the 
grave error of being too rigid in the enforcement of his theory, 
and I cannot agree with him in regard to his endeavor to secure 
entire absence of all external sources of irritation. Thus, binding 
the eyes and placing cotton in the ears would tend to frighten a 
child, while less radical measures, such as keeping the patient in 3 
bed in a quiet dark room, would be found to act much more 
beneficially. I cannot but think that Dr. Dexter's extreme 
measures would tend to irritate rather than to cure ; for, to close all 
avenues by which the mind can communicate with external things, 
would cause a restlessness that it should be our first object to 
avoid. 
This treatment for chorea, though directly at variance with the 
practice generally recommended, seemed to present strong argu- 
ments in favor of its efficiency, and in a clinical lecture at the 
Washington Hospital in the winter of 1876 I said, "The ex- 
aggerated movements of chorea seem to indicate the value of rest 
as a treatment; and I must say, that an experience in a limited 
number of cases, convinces me that the time is not far distant 
when prolonged rest will constitute the chief hope of the physician 
in his endeavors to overcome this morbid condition." The opinion 
expressed at that time has not been shaken by more extended 
observation, and I shall now explain the reasons that have induced 
me to adopt this theory. 
In a well marked case of chorea, if we ask the performance of 
some ordinary action, a reasonable attempt is made to do it; but 
before the action is carried out, the choreic spasm comes on, and 
this incoherence or insanity of muscles makes a compliance very 
difficult, or in some cases impossible. Now, if this complication is 
continued during the long and suffering day, the aggregate of 
unnecessary and irregular movement is immense; the nerve centres 
have gradually become more and more irritable, and when night 
finally comes, sleep is either much broken or disturbed. Observe 
the same patient on rising and you will find a decided decrease of 
the restless motions; but order a long walk, and on the patient's 
return it would not take a medical eye to detect the increase of 
spasmodic tendency. 
In a choreic patient any voluntary motion brings on many exag- 
gerated movements, both during the endeavor to carry out the 
design and after its imperfect performance. It may be stated then 
as aclinical fact, that any exercise or fatigue, far from being bene- 
ficial, exerts a most baneful influence, and not only causes a 
temporary increase of bad symptoms, but tends to render the 4 
central irritability more deeply fixed, and the diseased habit more 
difficult to eradicate. Hence it seems reasonable to conclude, that 
if we reduce all motion to a minimum, we will correspondingly 
reduce the tendency to choreic action, and thus prevent to some 
extent the formation of a habit, and give to the muscular system 
the complete rest which its irritable condition seems to demand. 
To furnish proof of these opinions, I shall briefly allude to eight 
cases of chorea that have been under my care during the last two 
years, and in all of these the element of rest has been the main 
factor of a treatment which has been singularly successful. 
Case No. 1.-Girl thirteen years of age, of no rheumatic history 
and no cardiac complications, developed chorea after an intense 
anxiety or fright, and in the course of three weeks grew rapidly 
worse under ordinary treatment. When 1 first saw her the mus- 
cular agitations were intense and distressing. Every attempt at 
movement was followed by a long series of choreic spasms. Her 
expression was listless, and formerly a bright girl, her mind had now 
become dull and stupid. It was even difficult to give nourishment, 
which could only be taken in a fluid form. A room was selected 
as the one in the house most free from noise and bustle; she was 
ordered to remain in bed, the windows darkened, and no one but 
the nurse was allowed to be with her. Of course, at first it was 
difficult to keep her quiet in bed ; in fact, sometimes the contortions 
were so violent as to necessitate the use of force to keep her in a 
recumbent position. But in forty-eight hours an evident improve- 
ment had taken place. The rest had produced a minimum of 
movement, and a consequent and marked diminution of choreic 
disturbance. She now expressed herself as satisfied to stay in bed, 
for she felt so much more comfortable; light wine and a diet as 
generous as her condition would allow, were ordered. During two 
weeks in bed she grew rapidly better, and at the end of that time 
she had resumed her natural appearance in almost every way. 
The choreic tendency was hardly perceptible, many movements 
being performed without any spasmodic results. This patient 
took kali brom. grs. 30, largely diluted in water, at night, and 
during the day sol. kali arsenitis gutta) 15. It must be stated, 
however, that before commencing the element of rest, both these 
drugs had proved of no benefit in her case. 
Case No. 2.-Girl eleven years of age. After spring examina- 
tions at school became irritable and restless. Soon after this she 
developed the uneasy movements of chorea. For two weeks she 
has been under the care of a physician, and has been growing rapidly 
worse. She always walked to his office, and after this medical 5 
excursion the patient was invariably more restless. As soon as she 
came under my care I ordered her to bed in a darkened room, to 
be kept as quiet as possible. Every form of excitement was 
avoided, and in three days the child was very much better. After 
nine days of absolute quiet this patient presented no evidence of 
chorea, and in fourteen days she was allowed to sit up, and a few 
days after to walk out. In this case I tested the value of massage 
as an addition to the rest. I found that such passive exercise did 
not irritate the patient to choreic movements, and that it was a 
very necessary adjunct to the treatment. 
Case No. 3.-Boy eight years of age. For ten days before see- 
ing me he has had jerking movements of his limbs, and now 
chorea is quite well marked. In this case the disease was evidently 
not fully developed. He was ordered to bed to be kept very quiet, 
light wine and good diet, and to be massaged twice daily. The 
tendency to spasmodic movements became much less under this 
treatment, and in two weeks, much to his delight, he was allowed 
to get up. This case had evidently been curtailed in its course. 
Case No. 4.-Boy nine years of age. Soon after a severe blow 
on the right side of the head, developed a hemichorea bn the same 
side of his body. This was about three months before I saw him. 
When he came to the clinic his condition was the following: the 
right side of his face, neck, the right arm and hand and right foot 
were in continual agitation with spasmodic movements. The 
right arm was wasted, being much thinner than the left, and he 
was unable to hold anything in his right hand. There was also 
evident paresis of the affected leg, as was shown in walking. This 
certainly was a very unpromising case for the rest treatment, for 
it had already shown itself persistent, and from its origin looked 
more serious than an ordinary case. Mainly on account of the 
chorea being on the same side as the blow on the head, it was 
thought that it did not arise from any local irritation under the point 
of injury. Hence he was treated in the same manner as the other 
children, and in two months, with the exception of slight remain- 
ing paresis, he had recovered entirely. 
Of the remaining four cases I will not speak, as they are ordi- 
nary examples of the disease, treated in the manner already 
described, all recovering after an average of two weeks of treat- 
ment. 
In regard to the use of medicines in chorea, I would say that if 
arsenic, or in fact any remedial measure, has an effect in this 
morbid process, surely its action should be much aided by repose. 
To a system reduced by suffering, tonics are necessary in the restora- 6 
tion to health ; and when sleep does not come naturally to a patient, 
of course some means to promote it must be resorted to. For these 
reasons I am accustomed to give sol. kali arsenitis during the day, 
and kali bromide at night, both in decided doses. But I am con- 
fident, from former experience, that these drugs are no more than 
adjuvants in this plan of successful treatment. 
In the exercise of this rest treatment, care must be taken to carry 
it out completely. Mere confinement in bed in a hospital ward is not 
sufficient. The presence of other patients, the passing to and fro 
of nurses, the bustle of administration, and numerous distractions, 
would give to a choreic patient much cause for restlessness. There- 
fore I would say as a sine qua non, that unless the rest is without 
interruption or irritation, it will be found, if not useless, of little 
benefit. 
Hence, it will be found necessary to provide an apartment for 
the patient where the blinds can be closed to avoid irritation by 
the eyes, absence of noise to avoid excitement by the ears, absence 
of any conversation to render the mind as quiet as possible. Add to 
these requisites an attendant who can be still and patient, to the 
advantages of good nourishment and necessary medicines, and you 
have a system which is essentially good and curative. 
It must be stated here that care should be taken to keep the 
patient in a condition not to be injured by too long confinement in 
bed, and I cannot do better than to quote, on this subject, from 
Prof. Wier Mitchell, in his article on " Rest in Nervous Diseases," 
Seguin's Medical Lectures, No. 4. " Think, then, when you put a 
person in bed, you are lessening the heart beats some twenty a 
minute, nearly one-third; that you are making the tardy blood to 
linger in the by-ways of the blood round, for it has its by-ways ; 
that rest prone binds the bowels, tends to destroy the desire to eat; 
and that muscles in rest too long get to be unhealthy and shrunken 
in substance. Bear these ills in mind, and be ready to meet them, 
and you will have answered the really hard question of how to 
help by rest without hurt to the patient." 
In all the cases after the first treated by this method, massage or 
passive exercise was ordered twice daily, and was found to aid 
materially in bringing about a good result. For in this way no 7 
choreic action was brought on, and the patient had the benefit of 
pretty thorough exercise twice daily. The circulation in the 
muscles is by this means promoted and actually excited, the torpor 
of the bowels is removed, and if the manipulations are carried on 
with care and assiduity, no ill effects result from it, and the 
injurious influences of confinement in bed are almost entirely 
counteracted. 
There is one symptom, however, in chorea which alone calls for 
this process of massage, without regard to the treatment by rest. 
This is the paresis and atrophy of muscles which occurs after the 
chorea has existed some weeks. The most marked example of this 
was in the case of hemichorea spoken of before. Yet it is to be 
found in all bad cases after the full development of the disease, 
and such an important indication demands this special attention 
and treatment. 
The use of massage, then, is not only necessary in counteracting 
the effects of prolonged rest, but it is a direct combat against the 
evil consequences of the disease, preventing, to a great extent, the 
atrophy, and preparing the muscles to resume their normal func- 
tions when the disease shall have been overcome. 
It seems difficult to believe that regulated movements, or calis- 
thenics, could have been recommended as a means of cure for a 
disease, which now seems to demand rest and quiet as the two 
essential points to bring about recovery. The long series of 
irregular movements brought on by these exercises could not have 
had a very beneficial influence, and the duration of the disease 
must have been needlessly prolonged by such recommendations. 
Indeed, I am forced to consider that this semi-homoeopathic system, 
of movements curing movements, will now be entirely abandoned. 
For whatever may be our idea of the pathology of chorea, the fact 
still remains that there exists a certain irritability of nerve centres 
which produces the most prominent symptom of the disease. In 
irritation or inflammation of any kind, whether of a joint or nerve, 
or of the bowels, or any mucous surface, the first indication in a 
wise treatment is rest. 
It is from reasoning somewhat in this manner that I have been 
led to adopt the ideas advanced in this paper, and my observations 8 
in practice concerning their influence and applicability are certainly 
satisfactory and encouraging. 
It would be very interesting to enter into comparative experi- 
ments as to the results in this treatment; but as in all such proce- 
dures the element of error is so hard to eliminate, and the manifest 
difference of every case so apparent, that the prospect of producing 
anything satisfactory is rather doubtful. Therefore, for the 
present, at least, I shall be satisfied merely to emphasize the im- 
portance of rest in the treatment of chorea, by the relation of these 
cases, and by this epitome of argument in its favor. If time shall 
ripen the truth of these reflections, further discussion of the subject 
will be necessary and interesting. 
In these remarks on chorea I have endeavored to give to the 
Society a new view of the treatment of a disease, which though it 
may be seen but rarely in general practice, is none the less inter- 
esting on that account. It is a treatment which may be termed 
moral or physical, but it is also essentially medical, for it suggests 
a means to alleviate and allay the most prominent, and, in fact, 
the characteristic feature of the disease. 
The value of rest in the management of chorea will, I am confi- 
dent, become in time an established fact among the best medical 
men; and I shall feel no slight reward, if the suggestions in this 
paper induce more able minds and more accurate observers to 
prove its usefulness and test its value.